Recruiting health professionals to the COVID-19 response, Brazil

Abstract Problem The coronavirus disease 2019 (COVID-19) pandemic posed a major workforce challenge to Brazil, which has a large land area and a shortage of health workers in regions distant from the big cities. Approach The Brazilian health ministry implemented a computerized solution to provide rapid support to states and municipalities to hire health professionals from large urban centres to work in underserved areas during the COVID-19 pandemic. We designed an online system for health professionals to register their willingness to work on the COVID-19 response; the system was launched to the public in April 2020. Local setting Brazil is a large country with great heterogeneity in access to health care across its different regions. Before the initiative was launched, 5 156 020 health professionals were officially registered with professional councils. However, an estimated 3 200 000, more than 60% of them, were working in the two regions with the highest standard of living. Relevant changes Up to February 2022, 1 007 138 health professionals had self-registered on the system, providing a sizeable database of professionals from a range of disciplines. Of these, 371 275 professionals were willing to work on the COVID-19 response in remote areas. By 1 February 2022, 157 755 professionals have been trained and deployed to these underserved areas. Lessons learnt Partnership of the government with professional councils and the use of official communication channels were important strategies to improve registration and ensure the success of the scheme. We predict that the database will assist with future public health campaigns in Brazil.


Introduction
The coronavirus disease 2019 (COVID-19) outbreak was declared a pandemic by the World Health Organization in early 2020. Two years on, the pandemic still represents a major challenge for health systems, which must implement strategies to combat the spread of infection, restructure the health service network to meet the increased demand for treatment of respiratory symptoms, and continue to offer care for other health conditions. 1 Brazil too faced challenges such as a high demand for care, lack of hospital beds, illness of professionals, long-standing shortages of human resources and materials, and the need for professional training on the clinical management of people infected with COVID-19. 2,3 We describe how the Brazilian government implemented a computerized strategy to link health councils, health professionals and the government in the selection and assignment of health professionals to the most isolated and underserved regions of the country.

Local setting
The total population in Brazil is around 213.48 million people. Brazil's unified health system was established by the Brazilian Federal Constitution in 1988. 4 Since then, Brazil's government has decentralized tasks and resources and increased the supply and access to health services, which has had a positive impact on the population's health and mortality. 5,6 However, public health managers face some challenges in the implementation of the health policy, such as a lack of public infrastructure, lack of planning, difficulties in equitable distribution of resources across regions, lack of human resources in some areas, and resistance to changes in health-care models and practices. 5 While the two more developed regions of Brazil in terms of human development index have an estimated 3 200 000 (62%) of the 5 156 020 total health workforce, the two least developed regions have no more than about 700 000 (14%) of these professionals.
To meet the challenge of maintaining health assistance to all regions of the country during the COVID-19 pandemic, the health ministry coordinated workforce management policies and provided health professionals and institutional support to states and municipalities of the country. For this, the health ministry designed the initiative O Brasil Conta Comigo 7 to provide institutional support for the recruitment of health professionals during the COVID-19 pandemic.

Approach
The initiative was instituted through a government ordinance on 31 March 2020, 7 with the objective of training health professionals on COVID-19 clinical management protocols, after which they could participate in the national COVID-19 programme.
We designed an online system that would allow health professionals to self-register to work on the COVID-19 response. The aim was to create a database to support decisions on hiring health professionals by local health authority managers, thus facilitating the recruitment process, and ensuring that professionals were trained on clinical management protocols for COVID-19 infections. We developed the registration system following the model-view-controller architecture pattern, with Spring Framework (VMware, Palo Alto, United States of America), Java 8 (Oracle Corporation, Santa Clara, USA) and All health professionals registered with their respective health councils were eligible to participate in the strategy, regardless of whether they were public or private employees. If the professional was already in work, the central government was allowed (if the employee agreed) to request that the employer release the employee to work on the COVID-19 response. The system accepted the registration of the following professional categories to work in their area of expertise if their professional registration was up to date: biology, biomedicine, physical education, nursing, pharmacy, physiotherapy, occupational therapy, speech therapy, medicine, veterinary, nutrition, dentistry, psychology and radiology. To implement the initiative, it was necessary to rely on the assistance of professional councils, who provided the health ministry with a list of professionals to enable a comparative analysis and validation of registration information.
The information collected during registration and stored in the database can be divided into three sections: personal, professional and data relating to actions to combat COVID-19. The first section focuses on the storage of identifying and contact information. The second section focuses on data about the employment relationship, which facilitates analysing the professional's profile and for orienting and structuring future health ministry actions. The third section focuses on data collected about the professionals assigned to initiatives related to COVID-19. This section helps in the mapping of some conditions, such as the number of professionals with suspected or confirmed COVID-19 infection and the number of professionals working directly in the field. The entire registration process is done on a freely accessible, public website under the health ministry domain.
The database includes a dashboard which is used exclusively by the health ministry and allows data to be extracted on professionals who completed registration, those willing to act in initiatives to combat COVID-19, those willing to act in other initiatives, those who are not directly dealing with suspected or confirmed cases of COVID-19, and those who have completed training. It is possible to analyse the records by professional category, view the total number of records and their relationship with the total number of professionals registered by state or region in the regional councils, and present a percentage of records by category. It is also possible to obtain the recruitment status for each action registered in the system and analyse the number of professionals that the initiative needs and the numbers already recruited, remaining to be recruited, with a signed contract, being hired, on leave and with contracts finished.
After the launch of the registration tool in April 2020, the health ministry, in partnership with the professional councils, publicized the initiative and encouraged adherence to registration requirements through internal and external means of communication, such as social media and media channels.
In February 2022 we performed an analysis of the numbers of professionals registered and willing to work on the CO-VID-19 response by region and state. The health ministry maintains restricted and controlled access to the information. The data were shared with us, as developers of the registration system upon authorization of use for scientific purposes, thus respecting the principles of confidentiality and anonymity of the data.

Relevant changes
The tool for the registration of professionals was made available to the public on 2 April 2020. Within 6 months, the database grew to more than 1 million subscribers. Of these, more than 346 000 subscribers received training on the protocol for clinical management of COVID-19. By analysing the health ministry's database, we could identify the professionals, their specializations, place of residence and availability to participate in the COVID-19 care programme.
Up to February 2022, the database had 1 007 566 health professionals registered out of the total 5 156 020 health professionals registered with health councils. Table 1 shows the total number of professionals registered by professional category and the percentage of registrations out of the total number of health professionals registered in each health council in the country.
The total number of registrations by region and state in Brazil are represented in Table 2. The south-east region had the highest number of registrations of health professionals (498 345 people, 49.4%) followed by the south (187 293 people, 18.5%), north-east (185 818 people, 18.4%), mid-west (83 639 people, 8.3%) and north (52 471 people, 5.2%). The south and southeast regions together have a higher human development index compared with other regions of the country. 8 Of the total registrations, 371 275 professionals were willing to work on the COVID-19 response in remote areas. By

Lessons learnt
With the shortage of human resources in health services during the COVID-19 pandemic, this initiative supported the recruitment of professionals and expanded the supply of care at a time of great need. In addition, the initiative contributed and continues to contribute to the training of thousands of professionals to assist in the clinical management of COVID-19 in Brazil, thus improving the health care provided to the population. The results demonstrate the positive impact of the strategy in making human resources available to the northern region of Brazil, where the health system was severely affected by the high demand for the treatment of respiratory symptoms and high mortality rates. 9 The health workers will remain in underserved areas for as long as they are needed or as long as they wish to continue. The low participation of health professionals in the online registration was an initial obstacle we encountered during implementation of the initiative. In an attempt to mitigate this problem, the health ministry chose to adopt a strategy of wide dissemination of the initiative, partnerships with professional councils and the use of official communication channels in addition to print, television and digital media (Box 1). Another obstacle was difficulty in accessing the internet for staff in some regions of Brazil. It is likely that not all health professionals were familiar with digital media, which may have influenced the total number of registrations.
The development of the registration tool took place in just one month. Therefore, it was necessary to implement improvements after the tool was launched, and with it the inclusion of new registration fields. To solve this problem, emails were sent to registered professionals requesting them to update their data on the system. The initiative focused attention on usability and ease of registration by health professionals without jeopardizing the security of the data entered in the system. We predict that the database will assist with other public health needs in Brazil. Possible uses include the recruitment of professionals for vaccination campaigns, actions aimed at riverside populations and task-force groups to act in situations of natural disasters. ■ Competing interests: None declared.

Box 1. Summary of main lessons learnt
• Constructing a database of health-care professionals helped in the recruitment and distribution of human resources for the COVID-19 response in a middle-income country with a large land area. • Small municipalities with few resources or situated far from urban centres took advantage of the online registration system as a tool for public health management decision-making during the public health emergency. • The partnership established with professional health councils for publicizing the registration system enhanced the government's initiative.